Alberta Health. Opioids and Substances of Misuse. Alberta Report, 2017 Q2

Alberta Health Opioids and Substances of Misuse Alberta Report, 2017 Q2 August 16, 2017

Key points Apparent fentanyl drug overdose deaths In the second quarter of 2017, 119 individuals died from an apparent drug overdose related to fentanyl in Alberta. By comparison, 122 died in the first quarter of 2017. In 2016, 85 deaths related to fentanyl occurred in the second quarter. In the second quarter of 2017, 81 per cent of deaths occurred in larger urban cities (Edmonton, Calgary, Red Deer, Grande Prairie, Fort McMurray, Lethbridge, Medicine Hat). In the second quarter of 2017, the Calgary Zone (54) and Edmonton Zone (38) had the highest number of fentanyl deaths. In the most recent quarter, the Calgary Zone continued to have the highest rate per 100,000 person years at 13.1, compared to a provincial average of 11.3 per 100,000 person years. Apparent non-fentanyl opioid drug overdose deaths From January 1, 2016 to December 31, 2016, 218 individuals died from an apparent drug overdose related to an opioid other than fentanyl in Alberta. In the first quarter of 2017, 33 individuals died from an apparent drug overdose related to an opioid other than fentanyl in Alberta. This compares to 54 deaths related to an opioid other than fentanyl in the first quarter of 2016, and 42 deaths related to an opioid other than fentanyl in the last quarter of 2016. In the first quarter of 2017, 67 per cent of these deaths occurred in larger urban cities (Edmonton, Calgary, Red Deer, Grande Prairie, Fort McMurray, Lethbridge, Medicine Hat). In the first quarter of 2017, the Calgary Zone (15) and Edmonton Zone (8) had the highest number of these deaths. The Central Zone had the highest rate at 5.0 per 100,000 person years, compared to a provincial average of 3.1 per 100,000 person years. Apparent opioid (including fentanyl) drug overdose deaths Within the cities of Edmonton and Calgary, in 2016, the rate of opioid (including fentanyl) drug overdose deaths was highest among Eastwood in Edmonton, and Calgary Central and East in Calgary. While the rates were highest in these local geographic areas, 61 per cent of deaths in Calgary and 69 per cent of deaths in Edmonton occurred outside these areas. Within Edmonton and Calgary, the majority of individuals who died of an apparent opioid (including fentanyl) drug overdose death lived outside of the central urban core. Confirmed drug overdose deaths In 2016, among confirmed accidental drug overdose deaths, opioids and fentanyl were directly involved in 83 per cent of these deaths. In comparison, among confirmed suicide drug overdose deaths, opioids and fentanyl were directly involved in 38 per cent of these deaths Emergency Department visits In the first quarter of 2017, there were 2,402 emergency and urgent care visits related to opioids and other substances of misuse. This is significantly more than the first quarter of 2016, when there were 1,919 emergency and urgent care visits related to opioids and other substances of misuse. In the first quarter of 2017, emergency and urgent care visits related to opioids and other substances of misuse occurred among 2,057 unique individuals, of whom, 11 per cent had more than one visit. 2017 Government of Alberta 1

Disclaimer This surveillance report presents emergency department visit, drug dispensing from community pharmacies, emergency medical services, naloxone kit dispensing, and mortality data associated with opioids and other substances of misuse in Alberta. Data sources are updated at differing time periods. Results are subject to change based on differences in data submission schedules and updates from the various data systems. Data may change in later reporting as it is submitted by the medical examiner, health facilities, and pharmacies. Recent data may be less complete due to delays in data submission. The number of drug overdose deaths related to fentanyl/opioids may change (including increases/decreases in previous numbers) as certification of deaths can take six months or longer, and certification of cause of death may lead to a change in classification. Apparent deaths = Preliminary evidence suggests that the death is most likely a drug overdose. Confirmed deaths = A Medical Examiner has determined the cause of death based on all available evidence, and listed the cause of death on a death certificate (including the substances directly involved in the overdose). Confirmed deaths in this report are for all drug overdose deaths, not just drug overdoses related to fentanyl and opioids. Throughout this report: Q1 =January to March Q2 = April to June Q3 = July to September Q4 = October to December The fiscal year begins April 1 of given year and ends March 31 of the next year. Local Geographic Areas (LGAs) refers to 132 geographic areas created by Alberta Health (AH) and Alberta Health Services (AHS) based on census boundaries *Updated methodology: All rates are now calculated using person time contributed to the specified time period, rather than the annual population count for the given year. This method is used to establish better rate estimates, and allow for better comparison between time periods that are not full calendar years (i.e. quarters, year to date time periods). Therefore, comparing to quarterly rates from previous reports should be avoided. For more details on data sources and methods, please see the Data notes (page 25) section at the end of this report. 2017 Government of Alberta 2

Table of contents Mortality data: Apparent drug overdose deaths 5 Figure 1: Proportion of fentanyl vs. non-fentanyl related apparent opioid overdose deaths, by quarter. Jan. 1, 2016 to Mar. 31, 2017. Table 1: Number of apparent drug overdose deaths related to all opioids by quarter 5 Figure 2: Number of individuals who died from an apparent drug overdose related to fentanyl, by zone (based on place of death) and quarter. Jan. 1, 2016 to Jun. 30, 2017. Table 2: Number of apparent drug overdose deaths related to fentanyl by quarter. 6 Table 3: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to fentanyl, by place of death, by Zone. Jan. 1, 2016 to Jun. 30, 2017. Table 4: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to fentanyl, by place of death and city. Jan. 1, 2016 to Jun. 30, 2017. Figure 3: Number of individuals who died from an apparent drug overdose related to an opioid other than fentanyl, by Zone (based on place of death) and quarter. Jan. 1, 2016 to Mar. 31, 2017. Table 5: Number of apparent drug overdose deaths related to an opioid other than fentanyl by quarter. Table 6: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by place of death, by Zone. Jan. 1, 2016 to Mar. 31, 2017. Table 7: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by place of death and city. Jan. 1, 2016 to Mar. 31, 2017. Figure 4: Rate (per 100,000) person years and counts of apparent opioid (including fentanyl) drug overdose deaths, in the City of Edmonton, based on place of overdose, by LGA. Jan. 1, 2017 to Mar. 31, 2017. Figure 5: (Rate per 100,000) person years and counts of apparent opioid (including fentanyl) drug overdose deaths, in the City of Calgary, based on place of overdose, by LGA. Jan. 1, 2017 to Mar. 31, 2017. Pg. 5 6 7 7 8 8 9 9 10 11 Figure 6: Ratio of opioid (including fentanyl) drug overdose deaths to EMS opioid-related responses, in the City of Edmonton, based on place of overdose, by LGA. Jan. 1, 2016 to Mar. 31, 2017. Figure 7: Ratio of opioid (including fentanyl) drug overdose deaths to EMS opioid-related responses, in the City of Calgary, based on place of overdose, by LGA. Jan. 1, 2016 to Mar. 31, 2017. Figure 8: Place of residence of individuals who died of an apparent opioid (including fentanyl) drug overdose death in the cities of Edmonton and Calgary, by central urban core/non-central core status. Jan. 1, 2017 to Mar. 31, 2017. 12 13 14 2017 Government of Alberta 3

Figure 9: Median household income of neighbourhood where individuals who died of an apparent opioid (including fentanyl) drug overdose death resided, and number of deaths occurring in neighbourhood, in the City of Edmonton. Jan. 1, 2016 to Mar. 31, 2017. Figure 10: Median household income of neighbourhood where individuals who died of an apparent opioid (including fentanyl) drug overdose death resided, and number of deaths occurring in neighbourhood, in the City of Calgary. Jan. 1, 2016 to Mar. 31, 2017. Figure 11: Deaths due to an apparent drug overdose related to fentanyl, by sex and age. Jan. 1, 2017 to Jun. 30, 2017. Figure 12: Deaths due to an apparent drug overdose related to an opioid other than fentanyl, by sex and age. Jan. 1, 2017 to Mar. 31, 2017. Figure 13: Proportion of deaths due to an apparent drug overdose related to fentanyl, by medical history within the 30 days before the date of death. Jan. 1, 2017 to Jun. 30, 2017. Figure 14: Proportion of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by medical history within the 30 days before the date of death. Jan. 1, 2017 to Mar. 31, 2017 Mortality data: Confirmed drug overdose deaths 15 16 17 17 18 18 19 Figure 15: Number of confirmed drug overdose deaths in Alberta by drug causing overdose and year. 2014 to 2016. Emergency department visits 20 19 Figure 16: Rate of emergency department (ED) visits related to opioid use and other substances of misuse, by quarter and Zone, per 100,000 person years. Jan. 1, 2014 to Mar. 31, 2017. Emergency Medical Services data Figure 17: Rate (per 100,000) person years of Emergency Medical Services (EMS) responses to opioid-related events, by LGA. Jan. 1, 2017 to Jun. 30, 2017. Methadone & buprenorphine/naloxone dispensing from community pharmacies 20 21 21 22 Figure 18: Total unique individuals dispensed methadone indicated for opioid dependence from community pharmacies, by Zone and fiscal year. Figure 19: Total unique individuals dispensed buprenorphine/naloxone indicated for opioid dependence from community pharmacies, by Zone and fiscal year. Naloxone kit dispensing 23 Figure 20: Naloxone kits dispensed and distributed by registered site type. Jan. 1, 2016 to Jun. 30, 2017. Table 8: Number of sites registered to distribute naloxone kits. Jan. 1, 2016 to Jun. 30, 2017. 23 Figure 21: Naloxone kits dispensed/distributed by community pharmacies and other registered sites, by Zone. Jan. 1, 2016 to Jun. 30, 2017. Figure 22: Naloxone kits dispensed by community pharmacies, by Zone and month. Jan. 1, 2016 to Jun. 30, 2017. Data Notes 25 22 22 23 24 24 2017 Government of Alberta 4

Mortality data Apparent opioid drug overdose deaths (fentanyl and non-fentanyl related) Figure 1: Proportion of fentanyl vs. non-fentanyl related apparent opioid overdose deaths, by quarter. Jan. 1, 2016 to Mar. 31, 2017. 100% Proportion of apparent opioid drug overdose deaths 90% 80% 70% 60% 50% 40% 30% 20% 10% 43% 40% 42% 57% 60% 58% 26% 74% 21% 79% Opioids Fentanyl 0% Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 The proportion of apparent opioid drug overdose deaths related to fentanyl appears to be increasing relative to non-fentanyl opioid drug overdose deaths, from 57 per cent of all apparent opioid drug overdose deaths in the first quarter of 2016, to 79 per cent in the first quarter of 2017. Table 1: Number of apparent drug overdose deaths related to all opioids by quarter South Zone 7 5 10 11 5 38 Calgary Zone 47 57 61 66 68 299 Central Zone 18 18 13 24 13 86 Edmonton Zone 41 47 65 52 50 255 North Zone 12 15 7 10 19 63 Alberta 125 142 156 163 155 741 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 2017 Government of Alberta 5

Figure 2: Number of individuals who died from an apparent drug overdose related to fentanyl, by Zone (based on place of death) and quarter. Jan. 1, 2016 to Jun. 30, 2017. 140 700 Femtanyl related deaths 120 100 80 60 40 600 500 400 300 200 Cumlative total deaths 20 100 0 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 South Calgary Central Edmonton North Cumulative total 0 Since January 1, 2016, a total of 609 individuals in Alberta died from an apparent drug overdose death related to fentanyl, with an average of 102 per quarter. This includes 82 deaths where carfentanil was detected (29 in all of 2016, 30 in the first quarter of 2017, and 23 in the second quarter of 2017). From January 1, 2016 to June 30, 2017, the number of apparent drug overdose deaths related to fentanyl continues to be significant, with the trend appearing to have stabilized based on the most recent data. Table 2: Number of apparent drug overdose deaths related to fentanyl by quarter Total South Zone 4 2 5 6 5 6 28 Calgary Zone 30 38 43 51 53 54 269 Central Zone 11 6 5 17 7 8 54 Edmonton Zone 18 26 35 39 42 38 198 North Zone 8 13 3 8 15 13 60 Alberta 71 85 91 121 122 119 609 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 2017 Government of Alberta 6

Table 3: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to fentanyl, by place of death, by Zone. Jan. 1, 2016 to Jun. 30, 2017. 2016 2017 YTD* Count Rate Count Rate South Zone 17 5.6 11 7.2 Calgary Zone 162 10.0 107 13.1 Central Zone 39 8.1 15 6.2 Edmonton Zone 118 8.7 80 11.7 North Zone 32 6.5 28 11.4 Alberta 368 8.7 241 11.3 The Calgary and Edmonton Zones continue to have the highest number of these deaths. In the most recent quarter, the Calgary Zone continued to have the highest rate per 100,000 person years at 13.1, compared to a provincial average of 11.3 per 100,000 person years. Table 4: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to fentanyl, by place of death and city. Jan. 1, 2016 to Jun. 30, 2017. 2016 2017 YTD* Count Rate Count Rate Lethbridge 10 10.3 8 16.9 Medicine Hat 4 5.8 0 0.0 Calgary 155 11.7 98 14.9 Red Deer 23 21.0 9 16.3 Edmonton 103 10.6 65 13.3 Fort McMurray 9 11.0 8 19.9 Grande Prairie 10 13.4 9 23.4 Total 314 11.5 198 14.5 The cities of Calgary and Edmonton continue to have the highest number of these deaths. However, in 2017 YTD, the City of Grande Prairie had the highest rate of apparent drug overdoses related to fentanyl per 100,000 person years. *YTD = Jan. 1, 2017 to Jun. 30, 2017 2017 Government of Alberta 7

Figure 3: Number of individuals who died from an apparent drug overdose related to an opioid other than fentanyl, by Zone (based on place of death) and quarter. Jan. 1, 2016 to Mar. 31, 2017. 70 300 60 50 40 30 20 10 250 200 150 100 50 0 0 Since January 1, 2016, a total of 251 individuals in Alberta died from an apparent drug overdose related to an opioid other than fentanyl, with an average of 49 per quarter. The most recent two quarters suggest the number of these deaths may be decreasing relative to the first three quarters. However, the trend seen in the most recent two quarters may be a result of a reporting lag in non-fentanyl related apparent opioid overdose deaths. Table 5: Number of apparent drug overdose deaths related to an opioid other than fentanyl by quarter. Total South Zone 3 3 5 5 0 16 Calgary Zone 17 19 18 15 15 84 Central Zone 7 12 8 7 6 40 Edmonton Zone 23 21 30 13 8 95 North Zone 4 2 4 2 4 16 Alberta 54 57 65 42 33 251 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Femtanyl related deaths Cumlative total deaths Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 South Calgary Central Edmonton North Cumulative total 2017 Government of Alberta 8

Table 6: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by place of death, by Zone. Jan. 1, 2016 to Mar. 31, 2017. 2016 2017 YTD* Count Rate Count Rate South Zone 16 5.3 0 0.0 Calgary Zone 69 4.3 15 3.7 Central Zone 34 7.1 6 5.0 Edmonton Zone 87 6.4 8 2.3 North Zone 12 2.4 4 3.2 Alberta 218 5.1 33 3.1 The Calgary and Edmonton Zones continue to have the highest number of these deaths. In 2017 YTD, the Central Zone had the highest rate per 100,000 person years at 5.0, compared to a provincial average of 3.1 per 100,000 person years. Table 7: Rate (per 100,000 person years) and number of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by place of death and city. Jan. 1, 2016 to Mar. 31, 2017. Lethbridge 2016 2017 YTD* Count Rate Count Rate 4 4.1 0 0.0 Medicine Hat 4 5.8 0 0.0 Calgary 52 3.9 14 4.2 Red Deer 12 11.0 1 3.6 Edmonton 71 7.3 7 2.9 Fort McMurray 1 1.2 0 0.0 Grande Prairie 1 1.3 0 0.0 Total 145 5.3 22 3.2 The cities of Calgary and Edmonton continue to have the highest number of these deaths. In 2017 YTD the City of Calgary had the highest rate of apparent drug overdoses related to an opioid other than fentanyl per 100,000 person years. *YTD = Jan. 1, 2017 to Mar. 31, 2017 2017 Government of Alberta 9

Figure 4: Rate (per 100,000 person years) and counts of apparent opioid (including fentanyl) drug overdose deaths, in the City of Edmonton, based on place of overdose, by LGA. Jan. 1, 2017 to Mar. 31, 2017. Edmonton rate: 16.3 per 100,000 person years (n = 39) Number in blue circle represents counts (numerator) EDMONTON-MILLWOODS WEST Within the City of Edmonton, the LGAs with higher or significantly higher than average rates of opioid (including fentanyl) drug overdose deaths were Eastwood, Woodcroft West, and Northgate. However, 46 per cent of the total deaths occurred in LGAs outside of these areas. The place where the overdose occurred was the same as the individual s home address for 49 per cent of these deaths in Edmonton. Note: Place of death was used as the place of the overdose, except in instances where the place of death occurred in a hospital. In instances where the death occurred in a hospital, if EMS had responded to the individual for an opioid-related event within 24 hours of the death, the location of the EMS response was used as place of the overdose. If no EMS visit occurred within 24 hours, the hospital death was excluded. In Edmonton, a hospital was the place of death in 15 per cent of deaths. 2017 Government of Alberta 10

Figure 5: Rate (per 100,000 person years) and counts of apparent opioid (including fentanyl) drug overdose deaths, in the City of Calgary, based on place of overdose, by LGA. Jan. 1, 2017 to Mar. 31, 2017. Calgary rate: 15.3 per 100,000 person years (n = 49) Number in blue circle represents counts (numerator) Within the City of Calgary, the LGAs with higher or significantly higher than average rates of opioid (including fentanyl) drug overdose deaths were Calgary Centre and East, and Nose Hill. However, 47 per cent of the total deaths occurred in LGAs outside of these areas. The place where the overdose occurred was the same as the individual s home address for 67 per cent of these deaths in Calgary. Note: Place of death was used as the place of the overdose, except in instances where the place of death occurred in a hospital. In instances where the death occurred in a hospital, if EMS had responded to the individual for an opioid-related event within 24 hours of the death, the location of the EMS response was used as place of the overdose. If no EMS visit occurred within 24 hours, the hospital death was excluded. In Calgary, a hospital was the place of death in 27 per cent of deaths. 2017 Government of Alberta 11

Figure 6: Ratio of opioid (including fentanyl) drug overdose deaths to EMS opioid-related responses, in the City of Edmonton, based on place of overdose, by LGA. Jan. 1, 2016 to Mar. 31, 2017. Edmonton ratio: 1 death to every 5 EMS opioid-related responses EDMONTON-WOODCROFT EAST From January 1, 2016 to March 31, 2017, within the City of Edmonton, in general, the more centralized urban core has a higher number of EMS responses for opioid-related events to every opioid-related drug overdose death. Edmonton Mill Woods (South & East) had the least amount of EMS responses relative to opioid-related drug overdose deaths. 2017 Government of Alberta 12

Figure 7: Ratio of opioid (including fentanyl) drug overdose deaths to EMS opioid-related responses, in the City of Calgary, based on place of overdose, by LGA. Jan. 1, 2016 to Mar. 31, 2017. Calgary ratio: 1 death to every 6 EMS opioid-related responses From January 1, 2016 to March 31, 2017, within the City of Calgary, in general, the more centralized urban core has a higher number of EMS responses for opioid-related events to every opioid-related drug overdose death. The lower NW and SE of Calgary had the least amount of EMS responses relative to opioid-related drug overdose deaths. 2017 Government of Alberta 13

Figure 8: Place of residence of individuals who died of an apparent opioid (including fentanyl) drug overdose death in the cities of Edmonton and Calgary, by central urban core/non-central core status. Jan. 1, 2017 to Mar. 31, 2017. Edmonton: 44 opioid/fentanyl deaths 2% 59% 23% 16% Unknown address Outside of Edmonton Central urban core Non-central urban core Calgary: 60 opioid/fentanyl deaths 3% 83% 5% 8% Unknown address Outside of Calgary Central urban core Non-central urban core Within Edmonton, 59 per cent of individuals who died of an apparent opioid (including fentanyl) drug overdose death lived in the non-central urban core and 83 per cent in Calgary. Note: If the individual did not have an address listed or had no fixed address at the time of death, the most recent postal code listed on the Alberta Health Care Insurance Plan (AHCIP) population registry file was used to determine most recent place of residence if the individual was matched to the AHCIP. Edmonton central urban core: Boyle Street, Central McDougall, McCauley, Oliver, Queen Mary Park, Riverdale, Rossdale Cloverdale, Garneau, Strathcona, University of Alberta. Calgary central urban core: Downtown (including the Downtown West End and Downtown East Village), Eau Claire, Chinatown, Beltline, Connaught/Cliff Bungalow, and Victoria Park. 2017 Government of Alberta 14

Figure 10: Median household income of neighbourhood where individuals who died of an apparent opioid (including fentanyl) drug overdose death resided, and number of deaths occurring in neighbourhood, in the City of Calgary. Jan. 1, 2016 to Mar. 31, 2017. Number in blue circle represents counts The neighbourhoods with more than five opioid-related drug overdose deaths included Downtown Commercial Core (12), Penbrooke Meadows (7), Beltline (7), Montgomery (5), Downtown East Village (5), Forest Lawn (5), Acadia (5), Forest Heights (5), and Dover (5). Opioid-related drug overdose deaths were most likely to occur in neighbourhoods with a selfreported household income of $50,000 to $59,999 (31 opioid drug overdose deaths for every 10 neighbourhoods within this median household income range). Note: Household income was based on results from the 2011 NHS survey, and adjusted to 2017 dollars. 2017 Government of Alberta 16

Figure 11: Deaths due to an apparent drug overdose related to fentanyl, by sex and age. Jan. 1, 2017 to Jun. 30, 2017. 60 50 Propostion of fentanyl deaths 40 30 20 10 Female Male 0 15 19 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70+ 82 per cent of deaths due to an apparent drug overdose related to fentanyl were among males. Across both sexes, the age group with the highest number of deaths occurred among individuals spanning the ages of 30 34. Figure 12: Deaths due to an apparent drug overdose related to an opioid other than fentanyl, by sex and age. Jan. 1, 2017 to Mar. 31, 2017. 9 8 7 Female Male Propostion of opioid deaths 6 5 4 3 2 1 0 15 19 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70+ 49 per cent of deaths due to an apparent drug overdose related to an opioid other than fentanyl were among males. Among males, the age group with the highest number of deaths occurred among individuals spanning the ages of 20 24, 30 34, 35 39, and 50 59, and among females, 50 54. 2017 Government of Alberta 17

Figure 13: Proportion of deaths due to an apparent drug overdose related to fentanyl, by medical history within the 30 days before the date of death. Jan. 1, 2017 to Jun. 30, 2017. Within 30 days before death Pain related health service Methadone or buprinorphine/naloxone dispensed from a community pharmacy 2% 2% Mental health related health service 7% ED visit related to opioid/substances of misuse Substance abuse related health service 11% 11% Opioid dispensed from a community pharmacy 16% Antidepressant/anxiolytic dispensed from a community pharmacy 19% 0% 5% 10% 15% 20% Figure 14: Proportion of deaths due to an apparent drug overdose related to an opioid other than fentanyl, by medical history within the 30 days before the date of death. Jan. 1, 2017 to Mar. 31, 2017. Within 30 days before death Methadone or buprinorphine/naloxone dispensed from a community pharmacy 6% ED visit related to opioid/substances of misuse Pain related health service 7% 8% Substance abuse related health service Mental health related health service 14% 16% Antidepressant/anxiolytic dispensed from a community pharmacy 46% Opioid dispensed from a community pharmacy 57% 0% 10% 20% 30% 40% 50% 60% Among deaths due to an apparent drug overdose related to an opioid (including fentanyl) the most frequent health care utilization within the 30 days before the individual s date of death was a dispensation for an opioid, antidepressant, or anxiolytic. Significantly more individuals who died from an apparent drug overdose related to an opioid other than fentanyl had an opioid or an antidepressant/anxiolytic dispensed from a community pharmacy in the 30 days prior to death compared to those who died from an apparent drug overdose related to fentanyl. Note: 95% of individuals had their primary healthcare number (PHN) available and were included in this analysis. The above includes the number of individuals who sought one of the services at least once. Individuals can be counted in more than one category. Health service means a physician, inpatient, or emergency department visit. 2017 Government of Alberta 18

Confirmed drug overdose deaths (accidental and suicide) Figure 15: Number of confirmed drug overdose deaths in Alberta by drug causing overdose, manner, and year. 2014 2016. Many drug overdose deaths in 2016 are currently under review by the Office of the Chief Medical Examiner and have not been confirmed. Therefore, upon completion of all cases, the final number of total drug overdose deaths in 2016 will be higher than the current number. The numbers below are the confirmed cases as of June 30, 2017. 300 250 200 150 114 136 196 247 156 148 217 133 100 50 0 75 78 74 59 35 32 18 4 8 4 2014 2015 2016 Unintentional fentanyl overdose Unintentional non-fentanyl opioid overdose Unintentional drug overdose due to non-opioid drugs Non-opioid related suicides Non-fentanyl opioid related suicides Fentanyl related suicides From 2014 to 2016, 82 per cent of all drug overdose deaths were consistently an unintentional drug overdose. Since 2014, the number of unintentional drug overdose deaths involving fentanyl increased from 26 per cent to 51 per cent in 2016. Unintentional non-fentanyl opioid drug overdoses have remained stable, at around 30 per cent of all unintentional drug overdoses. From 2014 to 2016, 18 per cent of all drug overdose deaths were consistently an intentional drug overdose. Since 2014, the number of intentional drug overdose deaths involving fentanyl has remained around 5 per cent. Intentional non-fentanyl opioid overdoses have increased from 19 per cent to 34 per cent of all intentional drug overdoses from 2014 to 2016. Note: Certification of more complex drug overdose deaths involving less potent opioids and drugs may take longer than fentanyl related deaths to certify, and therefore, non-fentanyl drug related deaths are potentially underreported in 2016. The above includes deaths where the cause was due to acute poisoning or toxicity by an exogenous substance where the manner was intentional (suicide) or unintentional (accidental). Deaths as a result of chronic substance use were excluded. Deaths as a result of poisoning or toxic effects due to alcohol, carbon monoxide and household chemicals were excluded. Other drugs refers to prescription drugs (i.e. antidepressants, benzodiazepines), illicit drugs such as cocaine, methamphetamine and MDMA, and unspecified drugs. 2017 Government of Alberta 19

Emergency department visits Figure 16: Rate of emergency department (ED) visits related to opioid use and other substances of misuse, by quarter and Zone, per (100,000 person years). Jan. 1, 2014 to Mar. 31, 2017. ED visit rate per 100,000 350 300 250 200 150 100 Calgary Central Edmonton North South Provinical average 50 0 The rate of emergency department visits related to opioid use and substance misuse increased by 82.5 per cent from Jan. 1, 2014 to Mar. 31, 2017. However, from the fourth quarter in 2016 to the first quarter in 2017, the rate decreased by 3.2 per cent. Specifically, decreases in the rate of emergency department visits related to opioid use and substance misuse were seen in the Central, Edmonton, and North Zone. The rate of emergency department visits related to opioid use and substance misuse in the South Zone is still the highest on average (226.6 visits per 100,000 person years); approximately 25 per cent higher than the provincial average (181.9 visits per 100,000 person years). The Edmonton and Calgary zones had the highest number of emergency department visits related to opioid use and substance misuse, and on average per quarter made up 27 and 29 per cent of all provincial ED visits related to opioid use and other substances of misuse, respectively. Note: Includes ED visits for all behavioural and mood disorders due to opioid use, and poisoning by all substances-all causes. (All F11 and T40 ICD-10 codes, any diagnosis field) 2017 Government of Alberta 20

Emergency Medical Services data Figure 17: Rate (per 100,000 person years) and count of Emergency Medical Services (EMS) responses to opioid-related events, by LGA. Jan. 1, 2017 to Jun. 30, 2017. Edmonton rate: 90.4 per 100,000 person years (n =441) Calgary rate: 122.3 per 100,000 person years 18 Number in blue circle represents counts (numerator) From Jan. 1, 2017 to Jun. 30, 2017, the majority of EMS responses in Alberta related to opioid events occurred in the City of Calgary and the City of Edmonton (approximately 80 per cent). Of the EMS opioid-related events that occurred in Edmonton (441), the highest rate (347.5 per 100,000 person years) and count (131) was in the Eastwood area. Of the EMS opioid-related events that occurred in Calgary (806), the highest rate (692.5 per 100,000 person years) and count (215) was in Calgary Centre. Additional LGAs with significantly higher rates of EMS related events compared to the city rate were West Bow, Centre North, and Calgary East. Note: This data is from AHS EMS Direct delivery ground ambulance. Air ambulance and Contractors are not included. EMS opioid-related events refer to any EMS response where the Medical Control Protocol of Opiate Overdose was documented and/or naloxone was administered. 2017 Government of Alberta 21

Methadone & buprenorphine/naloxone dispensing from community pharmacies Figure 18: Total unique individuals dispensed methadone indicated for opioid dependence from community pharmacies, by Zone and fiscal year. Number of individuals 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 South Calgary Central Edmonton North Alberta 2013/2014 335 887 205 1,212 217 2,656 2014/2015 466 1,200 299 1,414 333 3,347 2015/2016 529 1,388 398 1,487 289 3,708 2016/2017 537 1,536 503 1,541 335 4,003 In Alberta, from fiscal year 2013/2014 to fiscal year 2016/2017, there was an average increase of 15 per cent in the number of individuals who were dispensed methadone indicated for opioid dependence from community pharmacies from year to year. Figure 19: Total unique individuals dispensed buprenorphine/naloxone indicated for opioid dependence from community pharmacies, by Zone and fiscal year. 3,000 Number of individuals 2,500 2,000 1,500 1,000 500 0 South Calgary Central Edmonton North Alberta 2013/2014 14 71 78 535 81 729 2014/2015 38 143 137 675 102 1,021 2015/2016 261 328 265 849 147 1,691 2016/2017 470 689 304 1,278 350 2,804 In Alberta, from fiscal year 2013/2014 to fiscal year 2016/2017, there was an average increase of 57 per cent in the number of individuals who were dispensed buprenorphine/naloxone indicated for opioid dependence from community pharmacies from year to year. The largest increase was seen in the most recent fiscal year (66 per cent). 2017 Government of Alberta 22

Naloxone kit dispensing and distribution Figure 20: Naloxone kits dispensed/distributed by registered site type. Jan. 1, 2016 to Jun. 30, 2017. Harm reduction agencies Community pharmacies Addictions & Mental Health Opioid dependency program Corrections Health centers Walk in health centers Private First Nations and Inuit Health Branch Post secondary institutions AHS regional housing 1,076 990 906 676 598 243 327 48 2 7,183 6,501 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 As of June 30, 2017, 18,562 naloxone kits have been dispensed in Alberta, and 1,707 reversals have been self-reported. The highest volume of naloxone kits have been dispensed from harm reduction agencies (39 per cent), followed by community pharmacies (35 per cent). Table 8: Number of sites registered to distribute naloxone kits. Jan. 1, 2016 to Jun. 30, 2017. South Calgary Central Edmonton North Total Community pharmacies 81 313 103 272 93 862 Addictions & Mental Health 1 13 6 9 8 37 AHS regional housing 3 1 4 Community Centre 2 4 2 9 17 Corrections 2 3 1 3 1 10 First Nations and Inuit Health Branch 1 1 4 8 14 Harm reduction agencies 2 1 1 3 2 9 Health centers 16 24 20 19 30 109 Walk in health centers 9 17 23 12 27 88 Opioid dependency program 4 2 4 2 12 Post-secondary institutions 2 3 1 6 Private 9 14 12 15 6 56 Medical First Response 7 9 10 8 18 52 Total 132 404 184 351 205 1,276 Note: Naloxone kits dispensing data from community pharmacies comes from the Pharmaceutical Information Network. All other kit distribution data comes from the AHS Take Home Naloxone Kit Program. 2017 Government of Alberta 23

Figure 21: Naloxone kits dispensed/distributed by community pharmacies and other registered sites, by Zone. Jan. 1, 2016 to Jun. 30, 2017. Naloxone kits dispensed 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 3,767 Community pharmacies Other registered sites 2,556 2,695 2,331 2,556 1,901 1,142 415 527 672 South North Edmonton Central Calgary Throughout the province, other registered sites are dispensing more naloxone kits than community pharmacies. The Calgary Zone dispensed the highest total volume of kits in the province (34 per cent). Figure 22: Naloxone kits dispensed by community pharmacies, by zone and month. Jan. 1, 2016 to Jun. 30, 2017. Naloxone kits dispensed 1000 900 800 700 600 500 400 300 200 100 0 North Edmonton Central Calgary South Cumulative total Jan Feb Mar Apr May Jun 2016 2017 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr MayJune 6,501 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Cumulative total kits dispensed The Calgary Zone has had the largest volume of Naloxone kits dispensed from community pharmacies, with an average of 142 kits per month. The Edmonton Zone dispensed the next highest volume with an average of 130 kits per month. Across Alberta, community pharmacies dispensed an average of 361 kits per month. The median age of an individual receiving a naloxone kit dispensed from a community pharmacy was 31 years, and 58 per cent were male. Since Jan. 1, 2016, 6,501 naloxone kits have been dispensed from community pharmacies in Alberta. Note: Naloxone kits dispensing data from community pharmacies comes from the Pharmaceutical Information Network. All other kit distribution data comes from the AHS Take Home Naloxone Kit Program. 2017 Government of Alberta 24

Data notes Data source(s) for report 1. National Ambulatory Care Reporting System (NACRS) 2. Alberta Health Care Insurance Plan (AHCIP) Quarterly Population Registry Files 3. Alberta Health and Wellness Postal Code Translation File (PCTF) 4. Pharmaceutical Information Network (PIN) 5. OCME MEDIC data 6. AHS EMS Direct delivery-ground ambulance services data 7. AHS Take Home Naloxone Program data Mortality data The following substances are included in the drug overdose categories. Fentanyl: fentanyl, 3-methylfentanyl, acetylfentanyl, furanylfentanyl, or carfentanil Opioids: non-specified opiate, heroin, oxycodone, hydromorphone, morphine, codeine, tramadol, U-47700, tapentadol, or methadone Other drugs: includes, but not limited to ethanol (alcohol) in combination with other substances, benzodiazepines, antidepressants, antipsychotics, acetaminophen, cocaine or methamphetamine. Emergency Medical Services data Emergency Medical Services (EMS) data comes from AHS EMS Direct delivery ground ambulance services. Air ambulance and Contractors are not included. AHS direct delivery does 97.7 per cent of the operational responses in the City of Edmonton, 99.9 per cent in the City of Calgary, and approximately 82 per cent in the entire province of Alberta. EMS opioid-related events refer to any EMS response where the Medical Control Protocol of Opiate Overdose was documented and/or naloxone was administered. Emergency visits Emergency Department (ED) visits are defined by the Alberta MIS chart of accounts. Specifically, the three Functional Centre Accounts used to define any ACCS (Alberta Care Classification System) visits into an emergency visit could be: 1. 71310 Ambulatory care services described as emergency 2. 71513 Community Urgent Care Centre (UCC). As of 2014, the UCCs in Alberta are listed below: Airdrie Regional Health Centre, Cochrane Community Health Centre, North East Edmonton Health Centre, Health First Strathcona, Okotoks Health and Wellness Centre, Sheldon M Chumir Centre, South Calgary Health Centre 3. 71514 Community Advanced Ambulatory Care Centre (AACC). As of 2014, the only AACC in Alberta is La Crete Health Centre 2017 Government of Alberta 25

Community pharmacy drug dispensing 1. The Pharmaceutical Information Network (PIN) Database is used to estimate dispensation events for the province between 2014 and 2016 only from community pharmacies. Variability can be dependent on the way the drug is prescribed. 2. The PIN database is up-to-date; to date, the PIN database has records up to Jun. 30, 2017. PIN records can change due to data reconciliations, which may affect results. Results are more stable with older data. Opioid dependency drugs are defined by the ATC code (Anatomical Therapeutic Chemical), as given in the table below. ATC Code Drug Name ATC Grouping N07BC51 Buprenorphine, combinations Drugs used in opioid dependence N07BC02 Methadone Drugs used in opioid dependence The following DINs were excluded since they are indicated for pain relief by Health Canada. 02247701, 02247700, 02241377, 02247699, 02247698, 02247694 2017 Government of Alberta 26